Report Summary

Title: Alleged Wrongful Death and Deficiencies in Documentation of a Patient’s DNAR Status at the Baltimore VA Medical Center, Maryland
Report Number: 19-05916-24 Download
Issue Date: 11/26/2019
City/State: Baltimore, MD
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that a patient “may have died wrongfully” by aspiration during resuscitation attempts, and that the patient had a Do Not Attempt Resuscitation (DNAR) order but resuscitation was attempted at the Baltimore VA Medical Center (facility), Maryland.

The OIG identified concerns related to DNAR documentation and communication, follow-up on a patient safety concern related to medication contraindications, and code blue documentation.

The OIG substantiated that the patient died due to aspiration pneumonia, and subsequent cardiopulmonary arrest, and that facility staff attempted resuscitation. The OIG was unable to determine if the cause of death was wrongful.

The OIG substantiated that facility staff attempted resuscitation on a patient with a DNAR status; however, there was no DNAR order when resuscitation was attempted.

The OIG determined that residents and physicians did not comply with documentation requirements for DNAR orders and DNAR progress notes and failed to effectively communicate the DNAR status to team members. The absence of physician DNAR orders and progress notes, the presence of full code orders in telemetry order sets, and the lack of physician communication regarding DNAR status to the nursing staff resulted in the healthcare team not having the information needed to appropriately intervene when the patient became unresponsive.

The OIG found that facility leaders failed to act on an identified pharmacy safety issue related to the administration of haloperidol in patients with Parkinson’s disease. The issue was not addressed until the OIG requested an update in February 2019.

The OIG found facility staff did not comply with code blue documentation requirements. The facility’s measures to identify and rectify challenges with resuscitation processes were insufficient. Facility leaders failed to hold clinical staff responsible for code blue documentation.

The OIG made four recommendations.